Fentanyl is no longer the only substance keeping addiction clinicians up at night. Some of the newest threats are being sold not by dealers, but at gas stations, smoke shops and online.
From potent animal sedatives contaminating the opioid supply in the Northeast and Midwest to concentrated kratom derivatives marketed as botanical supplements, the substances patients are using are changing faster than the systems built to respond to them. At the same time, technology is making behavioral addictions such as online sports betting more accessible than ever.
Becker’s asked three psychiatry and addiction medicine leaders what trends they are seeing among their patients, which drugs they expect to take off and what worries them most.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What drug trends are you seeing among the patient population? Are certain drugs showing up more often, is there one you expect to take off, or is there a drug that worries you most?
Itai Danovitch, MD, MBA. Professor and Chair of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center (Los Angeles): There are several significant trends occurring in addiction. With respect to drugs, a major trend is the increasing complexity, unpredictability and accessibility of the drug supply. Fentanyl remains a major concern, but clinicians in many regions of the country are now confronting an evolving mixture of adulterants. Xylazine, and now increasingly medetomidine, both potent alpha-2 agonists, may contaminate the opioid supply in the Northeast and Midwest. Medetomidine can produce prolonged sedation and a severe withdrawal syndrome that may require intensive care. Clinicians in those regions can no longer assume that what appears to be opioid intoxication or withdrawal is pharmacologically just opioid intoxication or withdrawal.
Another rapidly emerging issue is the use of kratom-related products. Kratom is an herbal substance with opioid-like effects, while 7-hydroxymitragynine, or 7-OH, is a potent kratom-derived compound. Both are widely available online and in smoke shops and convenience stores. The accessibility and lack of regulation can create a perception that these products are relatively harmless; however, regular use can produce significant dependence and opioid-like withdrawal. The American Society of Addiction Medicine is working on a guidance document for clinicians that should be available soon.
The other major trend is the growth of behavioral addictions, which appears to be amplified by technology. Online gambling is probably the clearest example. The expansion of online sports betting has placed a highly reinforcing activity on a device people carry virtually every hour of the day. But I think this reflects a broader phenomenon. Technology is making potentially addictive behaviors, including gambling, gaming, sex and shopping, increasingly accessible, personalized and frictionless. AI may accelerate this further by allowing digital platforms to become progressively better at learning what captures and sustains an individual’s attention. Here as well, ASAM is working on a new volume of the ASAM Criteria that will focus on behavioral addictions, expected to be released next year.
Mo Sarhan, MD. Medical Director at Caron Treatment Centers (Delray Beach, Fla.): The substance landscape continues to evolve. Alcohol remains the most common primary substance we treat, while substances are emerging faster than the systems designed to respond to them. Among patients with opioid use disorder, fentanyl-involved polysubstance use is now the norm. But the drug I’m watching most closely, and the one I expect to continue to take off, is 7-OH.
7-hydroxymitragynine is an alkaloid from the kratom plant. Natural kratom leaf contains only trace amounts of it. Manufacturers are now concentrating it into gummies, shots and tablets sold at gas stations and smoke shops. Functionally, it is an opioid marketed as a botanical supplement.
The trajectory is alarming. According to the CDC, kratom-related reports to U.S. poison centers rose about 1,200% between 2015 and 2025, to a record high. America’s Poison Centers projects a nearly 68% increase this year alone. About 1 in 4 people exposed to kratom or 7-OH alone were hospitalized.
We recently cared for a patient in his 20s with an alcohol use disorder who was acutely hospitalized after taking one shot of 7-OH and overdosed. He required two doses of naloxone for reversal of the opioid effect. He had never used an opiate, kratom or 7-OH before.
What worries me most is the gap between perception and pharmacology. There is a disconnect between what individuals think they are buying and what the substance can do. Patients who would never touch heroin buy 7-OH because the label says “plant alkaloid.” Federal regulators are catching up. The Drug Enforcement Administration has moved to temporarily place concentrated 7-OH in Schedule I, but until that order takes effect, these products stay on the shelves.
My message to clinicians: Ask every patient specifically about kratom and 7-OH, because most won’t volunteer information. Keep naloxone on hand, since it can reverse 7-OH toxicity, though repeated doses may be needed.
Robert Trestman, MD, PhD. Chair of Psychiatry and Behavioral Medicine at Carilion Clinic and Virginia Tech Carilion School of Medicine (Roanoke, Va.): Here in Virginia we continue to see high frequencies of cocaine, fentanyl derivatives and methamphetamines. I fully anticipate that derivatives of fentanyl and other opioid-like substances such as the orphines [a class of synthetic opioids] will become more common. They are simply too easy and inexpensive to synthesize, distribute and consume. The challenge for us, whether in emergency or chronic care situations, is helping to cope with the profound addictive qualities and frequently not knowing what our patients are actually consuming. We know that, even though they may believe they are taking something specific, what is actually in the pills, capsules or powders may be much more complex and toxic.
What worries me further is the evolving storm where there is continued, if not growing, societal unrest and economic instability that will together contribute to a likely increase in the use of substances to deal with the frustration, hopelessness and fears that people experience. We had been making significant progress in reducing opioid overdose deaths and in developing effective treatments for opioid addiction. However, the new substances are making this far more difficult and threaten many more lives in the days ahead.
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